In our early experience, the most frequent anatomic problem we encountered after laparoscopic fundoplication was herniation of the fun-doplication across the diaphragm.6 This has almost always occurred in one of four clinical scenarios. The first situation is the patient who strains or retches in the early postoperative period. Patients often report feeling something "pop" and usually develop chest pain immediately thereafter correlating with herniation of the fundoplication. This is a true surgical emergency. The herniation should be confirmed with water-soluble contrast radiography followed by a rapid return to the operating room for laparo-scopic or open reduction of the herniated stomach.
The second situation is the patient who has a similar event but more remote from the time of operation. Although these patients may develop severe acute pain after herniation of the fundo-plication, the return of symptoms is usually more insidious, and the time of herniation may be difficult to pinpoint. Under these circumstances, the herniation is more frequently heralded by the symptoms of heartburn, new onset dysphagia, or postprandial chest pain resulting from gas or food distending the mediastinal portion of the herniated fundoplication. These patients should be evaluated with a barium swallow and EGD. Depending on the length of time between the first operation and the development of the hernia, we will perform esophageal motility and/or a gastric emptying study to better define foregut physiology in this postoperative state in planning for a second surgery.
The third situation is even more insidious. In this situation, the patient develops a slow onset of recurrent or new symptoms (chest pain, dys-phagia, heartburn) in the absence of a precipitating event. In this scenario, the inciting etiology may be acquired esophageal shortening, rather than a transdiaphragmatic stressor.
In these patients, the indication for the primary operation was more frequently a giant hiatal (paraesophageal) hernia, esophageal stricture, or Barrett's esophagus. In these patients, the herniation likely occurred because of esophageal shortening that was not detected and adequately treated with an esophageal lengthening procedure at the first operation. Elective reoperation should include an esophageal lengthening procedure such as a Collis gastroplasty along with a reinforcement and closure of the esophageal hiatus.
The fourth presentation of fundoplication herniation is those with small herniation who usually remain asymptomatic. In our experience, nearly half of the patients who develop fundoplication herniation will be asymptomatic, especially if the first operation was performed for a paraesophageal hiatal hernia.7 If a patient with a small asymptomatic recurrent hernia is not anemic, and has no evidence of ulceration in the herniated fundoplication, we recommend a strategy of watchful waiting.
In summary, patients with acute postoperative herniation require an emergency operation, those with "event induced" recurrence should undergo elective reoperation, those with a recurrent secondary to esophageal shortening should undergo Collis gastroplasty and repeat fundoplication, and those with asymptomatic recurrence need not undergo reoperation at all.
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Gastroesophageal reflux disease is the medical term for what we know as acid reflux. Acid reflux occurs when the stomach releases its liquid back into the esophagus, causing inflammation and damage to the esophageal lining. The regurgitated acid most often consists of a few compoundsbr acid, bile, and pepsin.